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    Please be advised:

    Exceptions may be granted for extenuating circumstances constituting “good cause.” “Good cause” means that a person’s failure to act was not due to lack of diligence, but circumstances beyond their control which resulted in a loss of opportunity to enroll or make applicable changes to current plan elections.

    If your request for an exception does not meet these guidelines, or would create non‐compliance with Dallas Independent School District’s Cafeteria Plan, which qualifies under Section 125 of the IRS code of 1986, your appeal may be denied.

    Incomplete forms will be denied as invalid. Forms must include supporting documentation such as certificate of credible coverage, confirmation statements, divorce degree, marriage certificate, birth certificates, etc. You will have another opportunity to enroll or make changes during the next annual enrollment period or if you experience a Special Enrollment Event and notify the Benefits Department within 31 days of such event.

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      Acknowledgment to Pay Retro Premiums:

      Please understand that submitting a request for an exception to enroll or make a change is not a guarantee of coverage reinstatement, billing credit, or enrollment. If the request is approved, I agree to payroll deducted retro premiums consistent with the effective date of the approved exception, if applicable. Please do not submit this form if you are unwilling to pay retro premiums associated with approval.

      Link for submitting an appeal: